Is There Evidence for Mild Traumatic Brain Injury? A Case for the Expert Neuropsychologist

Traumatic brain injury occurs in many forms, ranging from a fall or blow to the head resulting in concussive injury, gun shot or other penetrating wounds or classic automobile or motorcycle impact. When there is impact to the head, the scalp, skull, the covering of the brain (meninges), and the brain itself are affected to some degree and respond to the insult differently. The manner, in which these various parts react, depends on many factors.

An independent forensic neuropsychological examination, also referred to as an independent medial examination (IME), is performed by a neuropsychologist who is hired as an independent contactor by a third party (i.e., attorney) seeking answers to specific questions related to brain-behavior relationships. The forensic neuropsychologist is typically involved in three types of litigation:

1) personal injury (i.e., head trauma, neurotoxin exposure, and electrical injury), 2) disability determination, and 3) criminal cases. Referral questions in civil litigation typically involve determination of the presence or absence of neurological and/or psychiatric disorders, causality related to a specific event or injury, prognosis, medical necessity of treatment, and/or disability status. The most frequent cases are those involving closed head injury although there has been an increasing demand for evaluation of the neuropsychological effects of neurotoxic exposure (i.e., Carbon Monoxide, pesticides, solvents), and effects of electrical injury.

In criminal litigation the neuropsychological examination may be used to assist in determining competency to stand trail, issue of responsibility for the crime, or in sentencing/mitigation. The scope of this paper focuses primarily on personal injury cases particularly those related to one of the most controversial, yet persistently disabling injuries involved in litigation; Mild Traumatic Brain Injury (MTBI).

Mild Traumatic Brain Injury is typically defined as, an injury to the head resulting in brief or no loss of consciousness, post-traumatic amnesia, and negative neuroimaging scans. Those suffering MTBI typically evidence a range of impairments and levels of disability that in the long run, are often poorly associated with injury severity. Few neurological disorders are as prevalent as MTBI, which has an estimated incidents of 350,000 new cases each year and according to the National Center of Health Statistics, approximately 85% of all traumatic brain injuries are classified as mild. While most go unnoticed by the legal community, a large number of claimants seek legal representation for compensation of their sufferings.

Brain Damage vs. Cognitive Dysfunction

In personal injury litigation, the presence, extent, and nature of cognitive dysfunction may be central to an individual’s claim of damage. The assumption that any and all kinds of brain damage lead to similar behavior, and limitations in function are due primarily to severity of damages, is as erroneous as believing all roads lead to Rome. It is crucial to distinguish between brain damage and cognitive dysfunction. A brain damage is a pathological alteration of brain tissue identified by brain imaging techniques. It implies clear and structural injury to the brain. However, classification of changes in brain physiology that is not reflected in structural modification of the brain is defined as cerebral dysfunction. You may have had the misfortune of buying a brand new plasma television that did not work (despite having no physical damage). Typically, a technician is called to evaluate and test the parts causing it to malfunction. As in the case of the technician, the expert neuropsychologist administers test sensitive to even mild cognitive impairments. By administering these standardized tests, we can document the areas of the brain malfunctioning and its effects on quality of life. While the neuropsychologist job is more complicated then a television technician’s, the principle is the same.

The brain controls how we think, behave and feel. Just because there is no structural damage to the brain, does not mean there is no cognitive dysfunction. A patient may have negative neuroimaging scans such as computerized tomography (CT), magnetic resonance imaging (MRI), electroencephalogram (EEG), single-photon emission computerized tomography (SPECT), functional MRI (fMRI), and positron emission tomography (PET), and continue to experience cognitive or behavioral difficulties. As advanced and technologically sophisticated as they may be, neuroimaigng cannot explain why a claimant is reporting difficulty returning to work or managing daily responsibilities or making decisions. The forensic neuropsychologist, trained and experienced in assessment of cerebral dysfunction and its impact on quality of life, could answer those and other questions. When a patient sustains a MTBI from an accident, the damage to the brain may be none or minimal, but the consequences could still be catastrophic.

Brain Trauma 101

Traumatic brain injury occurs in many forms, ranging from a fall or blow to the head resulting in concussive injury, gun shot or other penetrating wounds or classic automobile or motorcycle impact. There are constellations of symptoms produced by different kinds of injuries, including neurological, psychological, affective, cognitive, and behavioral. When there is impact to the head, the scalp, skull, the covering of the brain (meninges), and the brain itself are affected to some degree and respond to the insult differently. The manner, in which these various parts react, depends on many factors. All of these combine to produce the final product or result. This phenomenon is sometimes called “waterfall” because the physical event may produce primary injuries to one or more components of the brain. The primary injury produces local injuries that may be insignificant and can be repaired or resolved over a longer period of time, and those that cannot be repaired. As a result of primary injuries, secondary injuries may appear which may or may not be resolved over time. Those injuries produce various types of events, such as increased intracranial pressure, compromised blood circulation, and decrease oxygen in the brain. This domino effect may prevent resolution of the primary injury or complicate consequences of the original traumatic event.

ABOUT THE AUTHOR: Dr Haygoush KalinianDr. Haygoush Kalinian is a licensed psychologist with specialization in Neuropsychology. She is currently in private practice in San Juan Capistrano, CA where she evaluates and treats individuals 19-90+ who suffer from head injury, stroke, dementia and psychiatric disorders. Additionally, she is a member of the medical staff at Mission hospital and an adjunct faculty at Argosy University.

Dr. Kalinian obtained her doctoral degree (PhD) in Clinical Psychology with specialization in Neuropsychology from a graduate school in the bay area affiliated with Stanford University. She completed internship in Neuropsychology in the Dept. of Physical Medicine and Rehabilitation at the University of California-Davis Medical Center and a postdoctoral fellowship in Neuropsychology in Dept. of Psychiatry at the University of California-San Francisco’s General Hospital. She also has a Master’s degree in Forensic Psychology from John Jay College of Criminal Justice.

While every effort has been made to ensure the accuracy of this publication, it is not intended to provide legal advice as individual situations will differ and should be discussed with an expert and/or lawyer.For specific technical or legal advice on the information provided and related topics, please contact the author.